Basic Information
| Provider Information | |||||||||
| NPI: | 1114213394 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KND DEVELOPMENT 59, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | 4834 KH NORTHLAND | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 S 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402022407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025967300 | ||||||||
| FaxNumber: | 5025964150 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 NW 68TH ST | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641182455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164206300 | ||||||||
| FaxNumber: | 5025964150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2011 | ||||||||
| LastUpdateDate: | 05/28/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POCKRUS | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR REG DIR PAT ACCT HD, MID SOUTH D | ||||||||
| AuthorizedOfficialTelephone: | 5025967358 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KINDRED HEALTHCARE, INC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | MA2353 | 01 | MO | MEDICARE | OTHER | 1114213394 | 05 | MO | MEDICAID |